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2< ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY Program Coordinators <br /> Donna K.Heran,R.E.H.S. Kasey L.Foley,R.E.H.S. <br /> Director 600 East Main Street, Stockton, California 95202 Robert McClellon,R,E.H.S. <br /> Telephone:(209)468-3420 Fax;(209)4b8-3433 Jeff Carruesco,R.E.H.S. <br /> ,Web: www.sjgov.org/ehd Linda Turkatte,R.E.H.S. <br /> SITE HEALTH& SAFETY PLAN <br /> PART I PART II <br /> GENERAL SMATION EVALUATION OF POTENTIAL HAZARDS <br /> i. Site Name:* 1. Chemicals Hazards <br /> Address: 0 Carcinogens: <br /> Contact L-f 7 ❑Corrosives: <br /> Phone#: ❑Dusts. <br /> Proposed Date of investigation/inspection: C) ,L3 G ❑Explosives: <br /> "Flammables: <br /> Y <br /> 2. Description and brief narrative of inspection activity: ❑Inorganic Gases: <br /> ❑New UST installation C}UAR Investigation ❑Metals: <br /> ❑Tank Closure in Place [I TanklPipe Repair ❑Oxidizers: <br /> ❑Tank/Pipe Removal ❑Re-excavation 0 PCBs: <br /> ❑Sampling ❑Boring I Monitoring Well installation IqOther: <br /> Wazardous Waste inspection C]Tiered Permitting inspection <br /> // PART III <br /> 3. Specific Site Information: REQUIRED PERSONAL PROTECTIVE EQUIPMENT <br /> Tank No.: Tank Capacity: I. Monitoring Equipment(Note:Monitoring instruments must be used for all <br /> Tank A e operations unless appropriate rationale or restrictions are provided): <br /> Tank Content: g <br /> ❑Combustible Gas/Oxygen Meter <br /> Other: <br /> ❑Detector Tubes(specify): <br /> E]Photo ionization Detector <br /> 4. Type of Operation: <br /> ❑Organic Vapor Analyzer <br /> 0 Other(specify): <br /> 5. Release History: <br /> N <br /> Evidence of leaks/soil contamination: E]YES ❑NO one(see below) <br /> Documented Groundwater contamination: ❑YES ❑NO If monitoring instruments are not used,rationale or activity/area restrictions: <br /> Background and description of any previous investigation or incidence: <br /> 2. Personal Protective Equipment <br /> Level of Protection: C3 A El B Cl C OD <br /> 6. Potential Health&Safety Physical Concerns:(✓all that apply&describe) Le Hard Hat <br /> ❑Heat or Cold Stress: IF(high ambient temp.) ®Safety Glasses/Goggles <br /> ❑Noise Sources: Steel toed/shank shoes or boots <br /> ❑Oxygen Deficiency: ❑Flame retardant coveralls <br /> [}Excavation(falls,trips,slipping,cave-ins): 0 Hearing protection <br /> Handling and Transfer of a Hazardous Substance(fire,explosions,etc.): ❑Tyvek <br /> 0 Respirator: ❑APR ❑SCBA <br /> ❑Confined space entry(explosions): A/P Cartridge- <br /> Heavy equipment(physical injury&trauma resulting from moving <br /> g Safety vest <br /> equipment): Qhai� <br /> ❑Other(specify): =Two-way cammunieation I <br /> ❑Other(specify): <br /> 7. Anticipated Biological Hazards: <br /> ❑Snakes Insects ❑Rodents ❑Poisonous Plants PART IV <br /> ❑Other/Unknown(specify): PLAN APPROVAL <br /> S. Narrative(provide all information which could impact Health and Safety, Plan Prepared b . <br /> Date: <br /> e.g.,power lines,integrity of dikes,terrain,etc.): - f_ ` <br /> Plan Approved by: r" Date: <br /> EH 23081(8/1112011) <br />